Of the 14 million cancer survivors in the United States, some have not yet had children but wish to plan a family, and some wish to have more children. Oncology nurses should be aware of the various options for fertility preservation prior to cancer treatment so that they can have discussions with their patients and refer them to fertility specialists when necessary.
“Oncology nurses can play a significant role in guiding patients interested in parenthood after cancer treatment. A systematic approach can be helpful in communicating about fertility and family building,” stated Joanne Frankel Kelvin, RN, MSN, AOCN, clinical nurse specialist at Memorial Sloan Kettering Cancer Center in New York City. Kelvin spoke at the recent Oncology Nursing Society 39th Annual Congress.
Although clinicians recognize that discussions with cancer patients about fertility are important, there are many barriers, including lack of knowledge, time, and resources; concerns about the cost of fertility options; and not knowing where to refer patients.
For males and females treated with chemotherapy, the most gonadotoxic agents are alkylating agents, followed in descending order by platinum analogs and anthracyclines. The long-term effects of targeted therapies on fertility are not known.
Radiation also carries some risk of infertility, depending on the extent of the radiation field and the cumulative dose to reproductive organs.
Surgery may compromise fertility as well. Bilateral orchiectomy or bilateral oophorectomy can deplete the sperm and ovarian reserves, respectively. In addition, treatment that damages the pituitary gland can disrupt hormonal regulation of reproduction.
Fertility Preservation for Males
Approaches to fertility for postpubertal males include sperm collection/preservation techniques such as semen cryopreservation (sperm banking), electroejaculation, and testicular sperm extraction (TESE) from testicular tissue. None of these options can be offered to prepubertal males who do not have mature sperm. These techniques to preserve sperm must be completed before treatment is initiated, Kelvin said.
Steps can also be taken to reduce the gonadotoxicity of radiation, including testicular shielding during pelvic/inguinal field radiation and intensity-modulated radiation therapy.
Fertility Preservation for Females
Many treatments are gonadotoxic for females, depleting the pool of available ovarian follicles (also called ovarian reserve). If all the eggs are destroyed by cancer treatment, the patient goes into premature menopause. Even some of those patients with oocytes left after treatment will have premature menopause.
“Female cancer patients are at risk for premature ovarian failure and menopause at a young age,” Kelvin stated.
It is difficult to predict the full effects of cancer treatment on females. Many women will have diminished ovarian reserve but can become pregnant with the help of assisted reproductive technology, while other women will have a narrowed window of opportunity, she explained.
The 2 basic approaches for preserving fertility in females are cryopreservation of eggs or fertilized embryos and strategies to reduce treatment-related toxicity. As with sperm banking, cryopreservation for females must be completed before the initiation of cancer treatment.
Embryo cryopreservation entails egg retrieval under anesthesia, followed by in vitro fertilization with male sperm; embryos that are thus produced are then cryopreserved.
“Until recently, you couldn’t freeze eggs, but the latest technology allows cryopreservation of eggs. However, this technique is much more successful in younger women than in older women,” Kelvin noted.
Cryopreservation of embryos takes time and can delay cancer treatment, so expedited referral is needed for patients who choose this option. There is some concern that females with estrogen receptor–sensitive breast cancer who are treated with hormonal therapy to stimulate the ovaries prior to egg retrieval may be at increased risk, and these women are sometimes also given an aromatase inhibitor to lower estrogen levels. However, many oncologists are not comfortable using hormonal therapies for patients with breast cancer who require neoadjuvant chemotherapy due to bulky disease and lymph node involvement.
Patients need to know that egg retrieval carries risks of bleeding, thrombocytopenia, liver dysfunction, accidental puncturing of vascular pelvic mass, infection, and risks associated with anesthesia.
Cryopreservation of ovarian tissue is an experimental procedure that may be used in pre- and postpubertal females who cannot delay cancer treatment and thus do not have time for cryopreservation of eggs or embryos. This technique should be used only in patients who are at high risk of infertility from cancer treatment. Reimplantation of ovarian tissue is available at selected centers, but there is concern that the ovarian tissue may harbor occult cancer cells.
Some clinicians offer ovarian function suppression with a GnRH agonist 2 weeks prior to starting chemotherapy to protect ovarian follicles from treatment-related effects, but this is considered experimental, she said.
Message to Patients
“I hope this information inspires you to address fertility with your cancer patients before they start treatment. It can be helpful to use the phrase parenthood after cancer,” Kelvin said.
Kelvin J. Clinical lecture—parenthood after cancer treatment: discussing fertility with your patients. Presented at: Oncology Nursing Society 39th Annual Congress; May 1-4, 2014; Anaheim, CA.